Healthcare Provider Details

I. General information

NPI: 1386928679
Provider Name (Legal Business Name): JESSICA KATHERINE VICK B.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JESSICA KATHERINE BAKER B.S.

II. Dates (important events)

Enumeration Date: 10/05/2011
Last Update Date: 10/05/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

280 INTERSTATE NORTH CIR SE SUITE 430
ATLANTA GA
30339-2450
US

IV. Provider business mailing address

280 INTERSTATE NORTH CIR SE SUITE 430
ATLANTA GA
30339-2450
US

V. Phone/Fax

Practice location:
  • Phone: 770-956-8511
  • Fax: 770-956-8907
Mailing address:
  • Phone: 770-956-8511
  • Fax: 770-956-8907

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: